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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547203487
Report Date: 10/04/2021
Date Signed: 10/05/2021 08:59:47 AM

Document Has Been Signed on 10/05/2021 08:59 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:KG'S CARE HOMEFACILITY NUMBER:
547203487
ADMINISTRATOR:GAITHER, KARIFACILITY TYPE:
735
ADDRESS:586 N. BALMORALTELEPHONE:
(559) 784-3498
CITY:PORTERVILLESTATE: CAZIP CODE:
93257
CAPACITY: 6CENSUS: 4DATE:
10/04/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Kari GaitherTIME COMPLETED:
02:01 PM
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Licensing Program Analyst (LPA) M. Medina conducted an unannounced Annual Required inspection on this date. LPA met with Licensee, Kari Gaither and stated purpose of visit. COVID-19 guidelines and precautions are in placed and observed upon entry. All staff and visitors enter through one entry point. A temperature check and sign in book observed at entry point.

Facility observed to be clean and odor free. Two (2) residents present during today's inspection. Staff observed to be wearing face masks. Facility has a 30-day supply of PPE on site and available. Hand sanitizer readily available for staff and residents. Soap, paper towels available at all sink. Hand washing signs posted in the bathrooms.

Resident medication observed, a 30-day supply is available for residents. A 2-day supply of perishable and a 7-day supply of non-perishable of food available. All fire exits open freely and have to obstructions.

Fire extinguisher present with a service date of 03/03/2021. Carbon monoxide and smoke detectors present and observed operational.

No deficiencies were observed. Exit interview was conducted. Administrator was informed that as a COVID-19 precautionary measure, this report will be emailed.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE: DATE: 10/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/04/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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